This article explores how family planning methods have contributed to unintended pregnancy among the rural women in Bangladesh. The study was a cross-sectional survey of 3,300 women. Findings suggest that among the respondents about 29 percent of the pregnancies were unintended. Analysis was found that those who did not use contraceptive methods before their last pregnancy had reduced odds (OR=0.22) of experiencing unintended pregnancy compared to those who used modern contraceptive methods. Advocacy is needed to promote longer acting and permanent methods among the eligible couples to avoid unintended pregnancy.

Background

In Bangladesh most of the reproductive health programs are directed towards improving maternal health and family planning. These efforts lead to the decline of maternal mortality by 40% from 322 deaths in 2001 to 194 deaths in 2010 per 100000 live births, which may be attributable to remarkable progress in fertility decline, from a high level of 6.3 births per woman in the mid-1970s to 2.3 births per woman in 2011. Contraceptive use rate has also increased from only 8 in 1975 to 61 in 2011. Despite these recent achievements, maternal mortality still remains one of the prime challenges and also unintended pregnancy remained same for last three decades. Unintended pregnancy is typically exposed to the risk of abortion. In Bangladesh, abortion-related complications contribute to about one-fourth of all maternal deaths. Besides this, the rate of unintended pregnancy is also one of the most basic measures of the situation of women's reproductive health, and of the level of women’s autonomy and capacity for self-determination. It signifies a woman’s capacity to determine whether and when to have pregnancies.

Objectives

According to 2011 Bangladesh Demographic and Health Survey (BDHS), in Bangladesh, 30 percent of pregnancies were unintended. The total intended fertility rate was 1.6 which is quite lower than the total fertility rate (TFR) 2.3. This means that if all unintended pregnancies could be eliminated, the TFR would drop below the replacement level of fertility immediately. High discontinuation rate, low use of long acting and permanent methods, erroneous use of family planning methods and unmet needs of family planning, in part or combined all contribute to the incidence of unintended pregnancies. Considering the situation, this article explores how family planning methods have contributed to unintended pregnancy among the rural women in Bangladesh.

Methodology

This article used data from the follow-up survey of evaluation of the Reproductive Health Voucher Evaluation project in Bangladesh. It was a quasi-experimental research design with pre and post studies in intervention and control areas and the assignment to the intervention was non random. It was conducted in 22 sub-districts where 11 sub-districts were selected as intervention areas. The other 11 sub-districts were selected as control areas. In this study a baseline survey was conducted in 2010 and a follow-up survey was conducted in 2012. A total of 3,300 women of 18-49 years of age were interviewed who gave birth in the previous 12 months from the starting date of data collection. Respondents’ socioeconomic and demographic characteristics as well as service utilization and perception of each service were collected by using a structured questionnaire in this survey. In this article, both bi-variate and multivariate analyses were used to examine strength of the relationship between the unintended pregnancy and use of family planning methods.

Results

Findings suggest that among the respondents (women) 68 percent wanted to become pregnant, 20 percent women wanted to wait or mistimed and another 12 percent did not want children any more. In other words, about 32 percent of the pregnancies were unintended. It was found that almost fifty percent (49 percent) of respondents were using a contraceptive method before their last pregnancy. Among them only one percent used a traditional method and rest 48 percent used a modern contraceptive method. Interestingly, the women who used (49 percent) any contraceptive before their last pregnancy, among them 46 percent experienced unintended pregnancy. On the other hand, non-users (51 percent) of contraceptive methods reported relatively lower proportion of unintended pregnancy (20 percent). The rate of unintended pregnancy also varied according to the use of contraceptive methods. The proportion of unintended pregnancy was comparatively higher among injectable users (51 percent) as compared to other method users.Logistic regression analysis was used to examine the odds of unintended pregnancy for each of the risk factors controlling for the others. It was found that those who did not use contraceptive methods before their last pregnancy had a reduced odds (OR=0.22) of experiencing unintended pregnancy compared to those who used modern contraceptive methods. Among contraceptive users, the likelihood of reporting unintended pregnancy was 1.6 times higher among the women who used traditional method as compared to modern contraceptive method users.

Conclusion

Findings suggest that the unintended pregnancy rate was higher among the contraceptive users before their last pregnancy than non-users. Again, the rate was higher among traditional and temporary modern method users as compared to longer acting modern method users. From several studies it has been explored whether the incidence of unintended pregnancy might decline more slowly than expected, and might even rise for a while, as countries move through the fertility transition. So, it can be assumed that the improvement of quality of family planning services is likely to decrease the level of unintended pregnancies in the future and advocacy is needed to promote longer acting and permanent methods among eligible couples to avoid unintended pregnancy.

This paper examined the impact of the intervention of a demand-side financing scheme on the utilization of services as well as out-of-pocket expenses incurred by women for availing of delivery care services. A quasi-experimental research design was conducted for this study. Findings reveal that there was a significant (p<0.0001) increase in the utilization of delivery care at public facilities in the intervention areas compared to the control areas. The average out-of-pocket cost or money required for a normal or caesarean delivery decreased over thirty percent over the time period. Demand-side financing had a positive effect on both utilization and cost.

Background

In rural Bangladesh, around 71% of births take place at home. Home delivery is preferred as it is associated with low cost and delivery care at facilities are only considered for emergency obstetric care (EmOC). Bangladesh is predominantly a rural, low income country with a vast majority of its people living in poverty. The utilization of skilled attendants at delivery was almost three times less in rural areas compared to urban areas and also it is seven times less among the poorest (9%) compared to the richer (63%) households. Borrowing, using household savings, and financial assistance from relatives were also found to be important sources in paying for the delivery care.
In the health sector of Bangladesh, the primary source of finance is out of pocket (OOP) expenditure and it is primarily spent in the private sector. Here 64% of total health care expenditure is paid by individuals and the rest by the government. In many situations, OOP payments for health care can cause households to incur catastrophic expenditures, which in turn can push them into poverty. Bangladesh has one of the highest rates of catastrophic illnesses which drives 3.8% of the population into poverty every year.

Objectives

To address this equity issue, the Government of Bangladesh piloted a demand-side financing (DSF) scheme (popularly known as the maternal health voucher program) in 21 upazilas (sub-districts) from 2006 and expanded to 33 upazilas in 2007. The selected poor women under DSF scheme receive a package of essential maternal health care services, as well as treatment of pregnancy and delivery related complications. This program also provides supply side financing to service providers. This program has been expanded to another 11 upazilas in 2010. Population Council, with funding from the Bill and Melinda Gates Foundation, has been evaluating the impact of voucher programs in five countries including Bangladesh. As part of evaluation activities, Population Council conducted a baseline survey in 2010 and a follow-up survey in 2012 in new 11 DSF (intervention) and 11 non DSF areas (control). This article used information from the baseline and follow-up survey to examine the impact of this intervention on utilization as well as out-of-pocket expenses incurred by women for availing delivery care services at facility.

Methodology

A quasi-experimental research design with pre and post studies in intervention and control areas was conducted to evaluate the impact of demand side financing vouchers on maternal health care services. The assignment to the intervention was non random. A baseline survey was conducted in 2010 with a follow-up survey in 2012. The study was conducted in 22 sub-districts where 11 sub-districts were selected as intervention areas where demand-side financing scheme was implemented. The other 11 sub-districts were selected as control areas where the demand-side financing scheme was not implemented. To draw a sample population, the national facility-based births figure was considered for baseline and follow-up survey and a total of 3300 women with 1650 experimental subjects and 1650 control subjects were selected. From each sub district, three of nine unions and three villages from each union were selected through probability proportional to size and finally, from each selected village, required numbers of respondents were interviewed. Women from 18-49 years of age were interviewed who had given birth in the previous 12 months from the starting date of data collection. Respondents’ socio-economic and demographic characteristics as well as service utilization and cost of each service were collected by using a structured questionnaire. Following the same sampling procedure, we interviewed the same numbers of respondents in the follow-up survey.
Out-of-Pocket Expenses: To examine the expenditure pattern, women were requested to report expenses on card/registration fees, consultation fees, laboratory examination, medicine, round trip transportation and any other associated costs to avail maternity care services. These expenses have been divided into three broad categories: medical cost at the facility, medical cost outside the facility, and transportation cost. “Medical cost at the facility” or internal medical cost includes card/ registration fee, consultation fee (unofficial), laboratory charges, drug cost (unofficial), tips to support staff for expediting services, and attendant expenditures for staying at the facility. Expenditures to purchase drugs and get laboratory services from the other private sector are considered as “medical cost outside the facility” and the actual cost women pay to transport providers is calculated as “transportation cost”.

Results

Information on the utilization of delivery presented in Table 1 indicates an increase in the proportion of the deliveries that occurred at the facility from 19 percent in 2010 to 31 percent in 2012 in the intervention areas with the control sites experiencing almost the same increase. Use of public-sector facilities for delivery services increased in intervention sites while control sites experienced greater increase in using the private sector. It has emerged from the 2010 & 2012 expenditure pattern that all delivery services involved OOP payments and the average volume of expenditure is higher in control than in intervention. Findings illustrated the average cost of different OOP expenses for receiving normal delivery services from public health facility. Cost incurred outside the facility (purchasing drugs and laboratory services) is the largest component (about half) of OOP expenditure for normal and cesarean delivery services in both areas. For that reason total average cost for normal delivery decreased a little bit in control areas also. Commonly, transportation cost increased in both intervention and control for normal or cesarean delivery.In the intervention group there has been a decline in the OOP cost for cesarean delivery that women incurred as medical cost both inside and outside the facility while an increase was reported for control. Reduction in both internal and external cost implies a positive impact of demand side financing benefits on women in receiving cesarean deliveries. With a mixed pattern of expenditure, the differences in OOP expenses between intervention and control that women incurred in 2012 cannot be explained with the effect of the DSF program.In the intervention areas, the average OOP cost for receiving normal delivery service reduced by 44% (from $40 to $22), and money required for a caesarean delivery decreased by 30% (from $115 to $80). Comparisons within public and private and voucher non-voucher has been made only in DSF upazillas. For the women external medical costs at private facilities were double compared to public facilities. Internal medical cost was four times higher at private facilities than at public facilities. In a two-year period, this expense remained same for public facilities while it increased three times for private facilities. Again, voucher clients spent much less money than non-voucher clients.

Conclusion

The recent shift in program development has taken place from being supply-side driven to being demand-side driven which improves the situation of non-accessibility of poor pregnant mother to the health facility. Findings reveal that there was a significant increase in the utilization of delivery care at the facility but it was also observed that the use of public-sector facilities for delivery services increased in only intervention sites while control sites experienced greater increase in the use of the private sector. The demand-side incentive package for the poor covers essential costs for maternal health care services and related to transportation cost also, while other costs like the purchase of additional medicine, unofficial provider fees and incidental costs incurred at facility are not covered under the program. Therefore, in DSF upazillas, there is no woman who did not incur any cost to utilize delivery services. Findings suggest the average volume of expenditure in receiving normal or cesarean deliveries is higher in control than in intervention areas. So, cost implies a positive impact of DSF benefits on women and this leads to the conclusion that DSF may have contributed to lower OOP payments. These findings necessitate the allocation of resources to subsidize the cost women incur to purchase medicine and undergo laboratory services that are not available in government facilities. Increased transportation expenses strongly justifies the need to increase the existing amount of financial assistance the government provides to poor clients. Without making normal delivery fully subsidized, it will be difficult to increase the institutional delivery rate as women still spends a large share of their family income for receiving normal delivery services.Besides this, implementing programs at the upazila hospital alone cannot raise the rate of delivery in rural areas. Additionally, for optimum utilization of the existing health structure in rural areas, other govt. facilities need to incorporate it. It was also observed that a large proportion of women are receiving services from private health facilities. Therefore, the national health financing strategies should engage the private health sector in a way that enables poor women to receive services from the private sector more easily. With the right types of interventions, maternal health-related MDG may not be very difficult to achieve in Bangladesh.